Data Collection Form

Please complete the details below.

1. Preferred Surname: *

2. Legal Surname (if different):

3. Legal Forename: *

4. Middle Name: *

5. Preferred Forename: *

6. Date of birth: *

YYYY

7. Gender: *

Male

Female

8. Brother/Sister in school: *

Yes

9. Name(s) of Brother/Sister(s): *

10. Address (Must include House Name or Number): *

11. Post code: *

Emergency Contacts:

Please give details of all persons who have parental responsibility and anyone else you wish to be contacted in an emergency. Place them in the order that you wish for them to be contacted.

1st contact

12. Parent/Guardian: Relationship to Pupil (e.g parent, step parent): *

13. Surname: *

14. Forename: *

15. Title: *

Mrs

16. Address: *

17. Postcode: *

18. Home telephone: *

19. Email: *

20. Work telephone: *

21. Mobile number: *

2nd contact

22. Parent/Guardian - Relationship to Pupil (e.g Parent/Step parent) *

23. Surname: *

24. Forename: *

25. Title: *

Mrs

26. Address: *

27. Postcode: *

28. Home telephone: *

29. Email: *

30. Work telephone: *

31. Mobile: *

3rd contact

32. Other Contact: Relationship to Pupil (e.g grandparent, Childminder): *

33. Surname: *

34. Forename: *

35. Title: *

Mrs

36. Address: *

37. Postcode: *

38. Home telephone: *

39. Email: *

40. Work telephone: *

41. Mobile number: *

42. Mobile number for texting service: *

43. Email address for Seesaw: *

44. Eligible for Free Meals (apply online at www.eani.org.uk/financial-help/free-school-meals): *

Yes

45. Medical Practice: *

46. Telephone: *

47. Address of Medical Practice: *

48. Medical Information: *

49. Special Dietary Needs: *

50. Previously Registered with a Sure Start project: *

Yes

Do not know

51. Attended a Sure Start Programme for 2-3 Year Olds: *

Yes

Do not know

52. Travel Arrangements: *

Bicycle

Train

Walks

Car

Taxi

School Coach

Public Transport

53. Has this child been Baptised in the Roman Catholic Religion?: *

Yes

If baptised outside Magherafelt Parish, please give place of Baptism - and Baptism Certificate must be presented to the School.

Please note: A pupil cannot receive the Sacraments of the Eucharist and Confirmation unless the school has a copy of the child's Baptism Certificate.

54. Place of Baptism: *

55. Previous School/Pre School: *

56. Date of Admission: *

YYYY

57. Reason for Leaving: *

58. Date of Leaving: *

YYYY

Data Protection Act 1998: The school is registered under the Data Protection Act for holding person data. The school has a duty to protect this information and to keep it up to date., The school is required to share some of the data with the Education Authority and with the Department of Education.

59. Religion: *

60. Ethnicity: *

61. Nationality *

62. Home Language: *

63. Do you need a translator for Parent/Teacher Meetings? *

Yes

64. Parent/Guardian Signature - Print name: *

65. Date: *

YYYY

66. Please confirm that you have read and agreed to the Policies (available on the website): *

Yes, I have read them

Website